Dead Alive Dead [Updated]

Emergency Medical Services — the paramedics, in other words — use a radio system called the patch telephone (which I am sure is not the correct technical name for it) to advise us of patients who are coming to the Emergency Department. Usually these are the critically ill, need-immediate-intervention-and-treatment patients, but sometimes not. The other day we got a patch about a patient that was definitely in the Not category. The patient had died in the ambulance, and EMS was requesting permission to proceed directly to the morgue.

This happens more often than you might think. The frequent scenario is that a patient already dying is sent to the Emergency because — let’s put the best spin on it — the nursing home staff has convinced the responsible physician the patient cannot be cared for appropriately in the nursing home setting (thus rendering superfluous, of course, any strictly delineated “No Transfer to Hospital” directives from the family), or else the patient is dying at home, and the family suddenly decides they can’t cope. In any case, it must be an ugly, unpleasant way to die, bouncing along in the back of an ambulance on, say, the 401.

Imagine our immense surprise, then, when the EMS crew arrived with the patient at Triage, the monitor faintly beeping. (What, she got better?) The nursing home had in fact decided the patient — who was a DNR and a “No Transfer” — had been “poor” for the last few days, and needed “a little IV fluid to perk her up.” EMS found her unconscious with agonal respirations, and on the way to the Emerg, she died. Literally. I saw the rhythm strips myself. Asystole. For a very lengthy period of time, long enough, anyway, for the paramedics to call to ask for the morgue key.

And then, claimed the paramedic, the ambulance hit a bump on the highway — and presto! she had a heartbeat again.* When she arrived, she was in an idioventricular rhythm. Not a great rhythm, but a rhythm and a thready pulse. But more importantly, she was not breathing spontaneously. Her pupils were already fixed.

She really was dead, but her heart hadn’t gotten the message yet. So we quickly off-loaded her into a Resus Room bed, and her heart stopped a few minutes later.

Again, it needs to be reiterated: this is a very crappy way to die. It astonishes me that nursing homes, which are supposedly equipped to deal with the frail and elderly, can’t cope well with the inevitable outcome of frailty and age.

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*[UPDATE] Okay, on reflection, the medics may have been pulling my leg a little on the bump. Maybe.

Amen, sister. It is a crappy way to die. I often wonder if any nursing home staff ever read these blogs, and can explain their rationale?

We had one rather notorious facility that did this all the time, but got around the “do not transfer” advanced directive by calling the family, insisting the family allow them to transfer grandma to hospital. When we called to ask why the patient was transferred despite the advanced directive, they would say, “The family requested it.” I once asked the family (gently!) why they requested the transfer, and they told me, “the home phoned us, and said we had to!”

One of my ER colleagues has a grandmother in a care facility right now. She says she has a very prominent note on grandma’s chart and kardex reading “do not transfer without grand-daughter approval” and her phone number. My colleague claims she has prevented her frail grandma from being ripped from her cozy bed in the middle of the night for a simple UTI on at least 2 occasions.